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Journal of Turgut Ozal Medical Center EDİTÖRE MEKTUP/LETTER TO THE EDITOR J Turgut Ozal Med Cent 2014;21(4):319-20 Journal of Turgut Ozal Medical Center www.jtomc.org Giant Prostatic Urethral Stone Dev Prostatik Üretra Taşı Caner Ediz, Serhan Çimen, Mehmet Levent Akbulut, Ramazan Altıntaş, Cemal Taşdemir, Ali Güneş İnönü University, Faculty of Medicine, Department of Urology, Malatya, Turkey Dear Editor, Urinary tract stones are often encountered in the upper an endoscopic ureter stone treatment. In the diagnostic urinary tract and the bladder but their incidence rate in cystoscopy performed in the lithotomy position, we the urethra is 1% (1). Urethral stones are divided into detected an urethral stone located in the prostatic two: as primary and secondary. Primary urethral stones urethra starting from the level of verumontanum. are rather rare while secondary urethral stones are frequently encountered in clinical practice. The treatment of urethral stones varies depending on stone localisation, size, and the structure of the urethra (2). We aim to present a giant urethral stone located in the prostatic urethra and to assess the case through a view of the related literature. A 58-year-old man was admitted to our clinic with pain in the left flank that had been present for a long time. The patient did not have any known metabolic diseases or previous surgeries. His physical examination was normal, too. The patient's arterial blood pressure was 120/85 mmHg and his body temperature was 36.8 degrees at his physical examination. The laboratory results were as follows: WBC: 7.400 K/L, HGB: 13.2 g/dL, and HCT: 39%, creatinine: 1mg/dl, respectively. The Figure 1. Nonenhanced CT Scan showing replacement of complete urine analysis results were WBC: 113/HP and prostate gland with calculi RBC: 22/HPF. There was no procreation in the patient's urine culture. Because of the fact that the stone was enclaved by the prostatic urethra, it was located close to the sphincter, To study the etiology of the pain on the left flank, we and that the stone did not give way to its proximal, and, first performed a urinary tract ultrasound. Urinary tract at length, considering its size and location, we decided ultrasound examination revealed perirenal abscess and to perform open surgery. The bladder was opened with hydronephrosis on the left. The right kidney was normal. vertical incision and the stone in the prostatic urethra We planned to perform an unenhanced abdominal was approached intravesically. Because the stone was computed tomography (CT). The abdominal enclaved by the prostatic urethra and the bladder neck tomography showed that the left kidney was slightly was not large enough for the removal of the stone, we decreased in size and that the pelvicalyceal system and could not take it out. We then tried the Millen method the proximal of the ureter were dilated. At the L4 level by reaching the prostate tissue from the retropubic of the 1/3 proximal part of the left uterine, there was an space. We incised the prostate tissue and removed the approximately 2 cm long stone; to the distal of the left approximately 5cm prostatic urethra stone. Due to the ureter at the level of the ureterovesical junction, there age of the patient and regarding the complications it was a stone density with two millimetric stones. The may cause, we did not interfere with the prostate tissue. bladder was normal. The prostate was 5,7x4,5x5cm in We did not plan any other interventions for the left size and there were calcification foci in the centre of the ureter stone in the same session. We thought that the prostate as large as 2.5x3.5x3cm combined with the current surgical area may bring about complications for prostate itself (Figure 1). the endoscopic treatment. With no intraoperative bleeding, the patient was discharged on postoperative We concluded that the patient should undergo a left day 2. The foley performed on the 10th postoperative ureterorenoscopy for his ureteral stone on the left and day showed no complications. Since then, for about six 319 Journal of Turgut Ozal Medical Center months, the patient did not have any issues concerning posterior urethra stones can be pushed into the bladder his urethral stone treatment. and then treated as bladder stones. If, however, there are additional pathologies like external mea stenosis or Urethral stones are rare among urinary tract stones yet urethral stricture, patients may need to undergo they are more common in developing countries in meatotomy or internal urethrotomy. In the treatment of contrast to western societies (3). They are rarer in larger stones or enclaved stones, neither of which are women due to anatomical factors (4). The most common not suitable for endoscopic therapy, practitioners may etiology of urethral stone is urethral stricture; in addition prefer ureterolithotomy or, if the stone can be pushed to this, urethral diverticulum, foreign bodies, urethral into the bladder, cystolithotomy. In our case, because fistula, and neuropathic bladder may be regarded as the giant urethral stone was not suitable for endoscopic secondary pathologies for the etiology of urinary tract lithotripsy, we needed to perform lithotomy with the infections (5,6). Besides, there are even studies that Millen method. report urethral stone formation without any predisposing factors (7). In our case, the findings did not As a result, urethral stones may exist without lower lead to any predisposing factors for the stone formation, urinary tract symptoms. It should be remembered that a either. definitive diagnosis may not always be possible through radiological methods. To this end, it is safe to state that The urethral stones, when they are smaller than 10mm, endoscopic methods is the most reliable way for the can pass through the urethra spontaneously. However, differential diagnosis of such cases. In addition, prostatic urethra, bulbous urethra, proximal penile preferring endoscopic methods to open surgery may be urethra, fossa navicularis, and external meatus are more appropriate in giant urethral stone cases as it was among the possible parts where an urethral stone get proved to be in our case. stuck (2). Because primary urethral stones grow slowly, patients do not usually consult with acute symptoms. REFERENCES Often appearing after long periods of time, patients often present with lower urinary tract symptoms such as 1. Drach GW: Urinary lithiasis: Etiology, diagnosis and medical difficulty in urination. In our case, in line with the management. In Walsh P, Retik A, Stamey, Vaughan D. Eds. literature, the patient did not present with acute Campbell’s Urology, 6th ed. Philadelphia: W.B. Saunders symptoms. 1992;2144-5. 2. Khai-linh V. Ho, MD Joseph W. Segura, MD: Lower Urinary Tract Calculi. Campbell’s Urology, 9th ed. Philadelphia: As in urinary tract stones, a large portion of the urethra W.B. Saunders p. 2007;2670-2. stones are radio opaque stones and they can often be 3. Amin HA: Urethral calculi. BJU;45:192-9,1973. diagnosed by plain radiography. Failing that, retrograde 4. Suzuki Y, Ishigooka M, Hayami S, Nakada T, Mitobe K: A urethrography and computed tomography can help with case of primary giant calculus in female urethra. Int Urol the diagnosis. However, definitive diagnosis can be Nephrol 1997;29:237-9. achieved endoscopically (2,3,8). Similarly, although the 5. Singh I, Neogi S. Male anterior urethral diverticula with initial radiological diagnosis was calcified foci in the Cobb’s collar and a giant stone. J Postgrad Med prostate in our case, the final diagnosis of the urethral 2006;52(1):73-4. 6. Vaddi SP, Devraj R, Reddy V, Vikram A, Dayapule S, stone was decided with the help of cystoscopy only. Munisami R. Urethral steinstrasse causing acute urinary retention. Urology 2011;77(3):594-5. Nowadays, due to the technological developments and 7. Kilciler M, Erdemir F, Bedir S, Çoban S, Erten K, Özgök Y: widespread use of endoscopic surgical techniques, Kliniğimizdeki üretral taşlı olguların literatür eşliğinde de- lithotripsy accompanied by ureteroscopy has become ğerlendirilmesi. Türk Üroloji Dergisi 2005;31(3):389-95. the first treatment option that comes to mind (9). 8. Aus G, Bergdahl S, Hugosson J, Lundin SE: Stone formation Location and size of the urethral stone along with the in the prostatic urethra after cryotherapy for prostate cancer. Urology 1997;50:615-7. presence of additional pathologies and condition of the 9. Rawlings C. Endoscopic removal of urinary calculi. urethra all play a determining role in the treatment of Compend Contin Educ Vet 2009;31(10):476-84. such cases. While stones can be removed with the aid of forceps if they are located in the anterior urethra, Received/Başvuru: 23.01.2014, Accepted/Kabul: 31.03.2014 Correspondence/İletişim For citing/Atıf için Ramazan ALTINTAŞ Ediz C, Cimen S, Akbulut ML, Altintas R, Tasdemir C, Gunes İnönü University, Faculty of Medicine, Department of A. Giant prostatic urethral calculus. J Turgut Ozal Med Cent Urology, MALATYA, TURKEY 2014;21:319-20 DOI: 10.7247/jtomc.2014.1691 E-mail: [email protected] 320 .
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